Getting everything you deserve from your health insurance sometimes requires putting up a fight.
If you receive notice that a claim for healthcare expenses was denied, don't just accept the decision. Healthcare providers frequently overturn claim denials. By following the steps below, you may be able to reverse your insurer's denial and improve your own financial situation as a result.
Investigate the denial: Start by figuring out why your claim was denied. Insurers usually provide a basic reason for their decision in the Explanation of Benefits (EOB) that accompanies their denial letters. You can get a full explanation by calling the customer service number on your insurance card.
Claim denials often stem from simple administrative errors, so there's a chance a phone call will be all that's needed to overturn a decision. Before you pick up the phone, gather relevant paperwork, including your EOB.
Once you've got a customer service agent on the line, find out whether your insurer deems your medical care not medically necessary or not covered by your plan. If you still believe your claim is legitimate after hearing your insurer's explanation, get details about the appeal process, including potential timelines and required paperwork.
Be polite, but don't hesitate to press for more details if the customer service agent simply repeats what you already knew or confuses you. Starting with this phone call, take careful notes on any communications with your insurer, including taking down the name and phone number of the person with whom you speak. This information could come in handy as the claims process progresses.
File an appeal: Now it's time to make your case. You should have a document, labeled Evidence of Coverage or Summary Plan Description, that explains what your plan covers and what it doesn't. (Many large insurers, like Aetna (Stock Quote: AET) and Humana (Stock Quote: HUM), post these documents online.) Read the document carefully, looking for any information that's relevant to your situation. For example, if your insurer says you failed to get prior authorization for certain medical care you received, check your plan documents to make sure prior authorization really was required.
